A man (we’ll call him Hector) had been on vacation and was hit by a car. His leg was shattered and he needed surgery in a place far from home. Without it, he risked losing his limb, so he decided to proceed. The operation went smoothly and he flew home a few days later.
Then, everything went wrong.
Within a week, his incision was hot, red and oozing. He went to the ER and was admitted for IV antibiotics. This happened again, and again.
Four hospitalizations later, the surgeons had to remove the hardware entirely. Leaving him with a botched surgery, chronic pain, and some very large bills.
You may be saying, “Of course that would happen, he got surgery abroad.”
Except, Hector wasn’t abroad.
His exotic vacation? Boston, Massachusetts, a premier US city known for medical excellence.
I met Hector when he was a patient of mine in the emergency room and unfortunately his story is not unique. Poor outcomes and complications can happen anywhere, including top US hospitals.
There’s a spectrum of performance in all industries, you probably see this in your own career. Some companies or employees are consistently above the rest and some are not so great.
It’s the same in healthcare, albeit likely more pronounced, because so many variables affect quality of care.
This makes sense but, for some reason, we assume that medical care abroad, from preventative testing to surgery, is of lower quality than in the US. People tend to oversimplify and base beliefs about safety of care on limited knowledge and preconceived opinions about other countries.
The reality is much more nuanced and you cannot solely assess quality by location, because even within the same system quality of care can drastically differ.
Let’s look at healthcare in the US to see how big this variation can be, and to understand how you can actually make an informed assessment to ensure that you’re getting the highest quality of care no matter where you are.
Pregnancy-Related Mortality: Systems Matter
It’s well documented that pregnancy-related deaths in the US are far higher than they should be.
Studies demonstrate that with 22 maternal deaths per 100,000 live births, we nearly double the rates of other high-income countries, sometimes even tripling. That’s right, the wealthiest nation in the world is leading its contemporaries in rates of maternal death.
What’s worse, this can vary by where you live in the US. States like Alabama (rate of 59.7/100,000) demonstrated 3 times the rates of maternal deaths as somewhere like California (18.5/100,000).
Clearly, a significant variation in outcomes and quality even within the same country’s health system.
Are OBGYNs in California just that much more skilled than their Alabama counterparts?
Looking to other countries can give valuable insight; it becomes clear that the disparity for moms is not due to a difference in skill, but a failure of the systems in place.
We can see significantly better outcomes (several countries with < 3 deaths/100,000) in places that have more robust systems for pregnancy care. These systems address some glaring issues that we know contribute to mortality in the US:
Postpartum care: All countries besides the United States in the Commonwealth Fund Report guarantee at least 1 home postpartum visit (2/3 of maternal death occur in the postpartum period, making this a crucial time).
Maternal leave: We are the only country discussed in the report that does not provide federally mandated maternal leave, further decreasing access to care before and after delivery.
Within the US, care can be even more fragmented with new mothers having limited follow up options depending on where they live.
These failings show how even in one of the greatest countries in the world, a lack of systems can have devastating repercussions.
As a consumer of healthcare, when evaluating quality, one of the most important things you can do is to make sure that proper systems are in place to keep you safe. Here are a few systems you always need to be checking:
Follow-up: Whether you’re getting a knee replacement or a whole body MRI, you need to have follow-up. For surgeries it’s crucial to have a robust plan for postoperative care (wound care, prescription use, visits and whether this is in person vs tele-health, etc.). For labs and imaging you need to know what’s next if there is an abnormality.
Documentation: Your provider needs to have easy to access documentation to provide you with accurate medical records for you to take with. This is commonly missed and your doctor at home can’t act on what they can’t see (meaning you’ll probably end up getting unnecessary testing if you don’t have adequate documents).
Communication: How easy is the provider to access and are they responsive? Are they willing to communicate with your other doctors (adding to follow up care)? Are they using text, WhatsApp, phone call, or digital portal? A poor communication system can have huge negative impacts on your care (you can’t get help from a dial tone).
Surgical Outcomes: A Volume Issue
Speaking to patients (and other doctors), I have often encountered the belief (assumption) that when it comes to surgery, America is uniformly the gold standard.
Taking a closer look, we have another example of why country does not indicate quality.
Surgery has been found to vary widely not just between hospital systems in the United States, but also within the same hospital network.
A study looking at surgical outcomes for hospitals within networks affiliated with US News & World Report Honor Roll demonstrated significant variation in complication and mortality rates.
Depending on the hospital you go to, you may have 2-4x more likely chances of serious complication or death, even within the same SYSTEM.
There’s also surgical literature suggesting that higher volumes of procedures are related to lower mortality, which intuitively, makes sense.
Clearly, if “results may vary” this much locally, it’s probably not empirically true that surgical care in the US is always the best. We need to be more critical about vetting our care anywhere.
So, how can you use this information? If you are planning on surgery, start here:
Evaluate your surgeon: focus on volume (procedure #/year), complication/revision rates, discussing who is actually operating (are there residents, PAs, etc), peri-operative follow up (touching back on systems). If this information isn’t published, don’t be afraid to ask, this is normal information to seek.
Evaluate your hospital/surgery center: Look for hospitals that are considered Centers of Excellence (specialize in a specific field, which means more volume) for the procedure you’re getting done. Again ask about volume of procedures, an average surgeon at a high volume center probably is better than an above average surgeon operating at a center that never does the procedure you need (systems matter).
Reputation isn’t always everything: “Prestige”, Ivy League credentials, word-of-mouth or online reviews can be useful, but only as a starting point. The reality is that there are bad doctors who trained or work at great institutions, and there are great ones who don’t. Reviews can be based off of emotion/miscommunication or many other factors (unfortunately they can also be fake). You need to do your own due-diligence.
Preventative Care: Poor Access = Poor Quality
Have you tried scheduling a doctor’s visit recently? If so, you probably understand this next point from experience.
From primary care to sub-specialists it can feel impossible to get a timely appointment, no matter who you are. That’s because the US has an access problem. Even though we spend the most on healthcare, we lag behind many other countries in access to care.
This can stem from too few providers, rising healthcare costs, insurance intricacies and more. No surprise here, but where you live can exacerbate this strain (rural areas, lower SES areas, etc.).
If you can’t get an appointment, you can't get care. This delays preventative testing or other interventions keeping people healthy and degrading quality of our healthcare system.
When you can finally see your doctor, they are often constrained by guidelines, insurers, and time which may leave you unsatisfied and more importantly without answers to your concerns.
The US model is designed to be reactive, meaning that your doctors order what’s considered “medically necessary,” which, unfortunately for you, doesn’t include early or broader preventive testing or more emerging longevity focused tests. This leaves even motivated, insured patients without access to the care they seek.
So, with limited access, here’s how you can protect yourself:
Know what preventative tests you need. Most people miss basic preventative tests because they just don’t know (colonoscopy screening at 45, cervical cancer screen every 3-5 years, etc.). You can find recommendations online at US Preventative Services site and this helpful tool from US Department of Health and Human Services.
Be explicit about your concerns. This can help doctors justify tests if they understand the underlying worry. Just be straight up with them, talk about what you are concerned about, it may not solve the problem, but it goes further than not saying anything.
Consider alternatives. Imaging centers, concierge/tele-health, longevity and wellness clinics have been exploding recently. International preventative testing is increasingly popular. If the traditional system can’t accommodate you, these are all well utilized options.
Wrapping up: How You Ensure Quality
By being introspective and taking a look at our own healthcare system in the US, it’s clear that the name of a country doesn’t mean much when it comes to quality and you can’t assume that the clinic down-the-block is always the best option.
We can see how care may vary more based on zip code than on country code, reflecting how important it is to be educated consumers when it comes to health.
Today, we increasingly have access to more information about the state of the healthcare industry around us. This reveals holes in the system, but it also presents us with the opportunity to take an active role in our own care.
Educating yourself on systems to ensure premium quality, evaluating individual clinicians/hospitals that are caring for you, and having affordable access to providers and proper testing are far more important than placement on a map.
Keep this in mind on when thinking of your own healthcare so you can get the service you deserve no matter where you are.
That’s all for today, I’ll be back in your inbox with a Sunday Short.
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Thanks for reading
Kyle
Other Posts: https://welltraveled.health/archive
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